Coordination of benefits
If you have coverage under other group plans, the benefits from the other plans will be taken into account if you have a claim. This may mean a reduction in benefits under the EMMP.
Benefits available through other group plans and/or no-fault automobile coverage will be coordinated with the EMMP. “Other group plans” include any other plan of dental or medical coverage provided by:
- Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured; and
- “No-fault” and traditional “fault” auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law.
To find out if benefits under the EMMP will be reduced, Aetna must first determine which plan pays benefits first. The determination of which plan pays first is made as follows:
- The plan without a coordination of benefits (COB) provision determines its benefits before the plan that has such a provision.
- The plan that covers a person other than as a dependent determines its benefits before the plan that covers the person as a dependent. If the person is eligible for Medicare and is not actively working, the Medicare Secondary Payer rules will apply. Under the Medicare Secondary Payer rules, the order of benefits will be determined as follows:
- The plan that covers the person as a dependent of a working spouse will pay first;
- Medicare will pay second; and
- The plan that covers the person as a retired employee will pay third.
- Except for children of divorced or separated parents, the plan of the parent whose birthday occurs earlier in the calendar year pays first. When both parents’ birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn’t have the parent birthday rule, the other plan’s COB rule applies.
- When the parents of a child are divorced or separated:
- If there is a court decree which states that the parents will share joint custody of a child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule, immediately above, applies.
- If a court decree gives financial responsibility for the child’s medical, dental or other health care expenses to one of the parents, the plan covering the child as that parent’s dependent determines its benefits before any other plan that covers the child as a dependent.
- If there is no such court decree, the order of benefits will be determined as follows:
- the plan of the natural parent with whom the child resides,
- the plan of the stepparent with whom the child resides,
- the plan of the natural parent with whom the child does not reside, or
- the plan of the stepparent with whom the child does not reside.
- If an individual has coverage as an active employee or dependent of such employee, and also as retired or laid-off employee, the plan that covers the individual as an active employee or dependent of such employee is primary.
- The benefits of a plan which covers a person under a right of continuation under federal or state laws will be determined after the benefits of any other plan which does not cover the person under a right of continuation.
- If the above rules do not establish an order of payment, the plan that has covered the person for the longest time will pay benefits first.
If it is determined that the other plan pays first, the benefits paid under the EMMP will be reduced. Aetna will calculate this reduced amount as follows:
- The amount normally reimbursed for covered benefits under the EMMP,
- Benefits payable from your other plan(s).
If your other plan(s) provides benefits in the form of services rather than cash payments, the cash value of the services will be used in the calculation.
Incorrect computation of benefits
If you believe that the amount of benefit you receive from the ExxonMobil Medical is incorrect, you should notify Aetna in writing or contact Aetna Member Services. If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits. (See Claims and Administrative and ERISA information sections.)
Recovery of payment
If the calculation of your or your beneficiary’s benefit results in an overpayment, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The plan administrator may make reasonable arrangements with you for repayment.
Right of recovery (subrogation and/or reimbursement)
If you or a covered family member receives benefits from this plan as the result of an illness or injury caused by another person, the EMMP has the right to be reimbursed for those benefits from any settlement or payment you receive from the person who caused the illness or injury. This means the EMMP may recover costs from all sources (including insurance coverage) potentially responsible for making any payment to you or your covered family member as a result of an injury or illness, including:
- Uninsured motorist coverage;
- Underinsured motorist coverage;
- Personal umbrella coverage;
- Med-pay coverage;
- Workers’ Compensation coverage;
- No-fault automobile coverage; or
- Any first party insurance coverage
What you need to know
Here are some important points about the right of subrogation:
The Plan has a lien on any payments you receive.
The EMMP automatically has a lien, to the extent of any benefits it has paid, on any payment you’ve received from a third party, his/her insurer or any other source. The lien is in the amount of benefits paid by Aetna under this plan for treatment of the illness, injury or condition for which the other person is responsible.
Your cooperation is required.
You may not do anything to interfere or affect the EMMP’s subrogation rights.
You also must fully cooperate with the EMMP’s efforts to recover benefits it has paid. This includes providing all information requested by the Claims Administrator or its representatives. As part of this process, Aetna may ask you to complete and submit certain applications or other forms or statements. If you fail to provide this information, it will be considered a breach of contract and may result in the termination of your health benefits or the instigation of legal action against you.
You must notify Aetna.
If a lawsuit or any other claim is filed to recover damages due to injuries sustained by you or a covered family member, you must notify Aetna. This must be done within 30 days of the date the notice of the lawsuit or claim is given to a person, including an attorney.
The Plan is paid first.
The EMMP’s subrogation rights are a first priority claim against all potentially responsible person(s), and must be paid before any other claim for damages.
The Plan is entitled to full reimbursement.
The EMMP is entitled to full reimbursement first from any payments made by any responsible person(s). This reimbursement must be made, even if the payment is not enough to compensate you or your covered family member in part or in whole for damages. The terms of this plan provision apply and the EMMP is entitled to full recovery whether or not any liability for payment is admitted by any potentially responsible person(s), and whether or not the settlement or judgment you receive identifies the medical benefits provided by the plan. The EMMP may be reimbursed from any and all settlements and judgments, even those for pain and suffering or non-economic damages only.
Aetna chooses the court for any legal action.
Any legal action or proceeding with respect to this provision may be brought in any court of competent jurisdiction Aetna selects. When you receive benefits under this plan, you agree to this rule and waive whatever rights you have by reason of your present or future place of residence.
The Plan is not responsible for your attorneys’ fees.
The EMMP is not required to participate in or pay attorney fees to the attorney you hire to pursue your claim for damages.
Interpreting this provision.
If there is any question about the meaning or intent of this plan provision or any of its terms, the EMMP will have the sole authority and discretion to resolve all disputes as to how this provision will be interpreted.
A claim occurs whenever a plan participant requests:
- An authorization or referral from a participating provider or Aetna; or
- Payment for items or services received.
You do not need to submit a claim for most of your covered healthcare expenses. However, if you receive a bill for covered services, the bill must be submitted promptly to Aetna for payment. Send the itemized bill for payment with your identification number clearly marked to the address shown on your ID card.
You must submit a claim form within two calendar years from the date of a service.
Aetna will make a decision on your claim using coverage policies and the definitions found in the "Key Terms section" of this document. For concurrent care claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.
Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.
Adverse benefit determinations can be made for one or more of the following reasons:
- The individual is not eligible to participate in the Plan; or
- Aetna determines that a benefit or service is not covered by the Plan because:
- it is not included in the list of covered benefits,
- it is specifically excluded,
- a Plan limitation has been reached, or
- it is not medically necessary.
Aetna will provide you with written notices of adverse benefit determinations within the time frames shown below. These time frames may be extended under certain limited circumstances. The notice you receive from Aetna will provide important information that will assist you in making an appeal of the adverse benefit determination, if you wish to do so. Please see “Complaints and Appeals” for more information about appeals.
Extensions of time frames
The time periods described in the chart may be extended.
For urgent care claims: If Aetna does not have sufficient information to decide the claim, you will be notified as soon as possible (but no more than 24 hours after Aetna receives the claim) that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after the additional information is provided.
For non-urgent pre-service and post service claims: The time frames may be extended for up to 15 additional days for reasons beyond the plan’s control. In this case, Aetna will notify you of the extension before the original notification time period has ended. If you fail to provide the information, your claim will be denied.
If an extension is necessary because Aetna needs more information to process your post service claim, Aetna will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information. Aetna will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after Aetna receives the information, if earlier). If you fail to provide the information, your claim will be denied.
Grievances and appeals
There are procedures for you to follow if you are dissatisfied with a decision that Aetna has made or with the operation of the Plan. The process depends on the type of complaint you have. There are two categories of complaints:
- Quality of care or operational issues; and
- Adverse benefit determinations.
Complaints about quality of care or operational issues are called grievances. Complaints about adverse benefit determinations are called appeals.
Quality of care or operational issues arise if you are dissatisfied with the service received from Aetna or want to complain about a participating provider. To make a complaint about a quality of care or operational issue (called a grievance), call or write to Member Services within 30 days of the incident. Include a detailed description of the matter and include copies of any records or documents that you think are relevant to the matter. Aetna will review the information and provide you with a written decision within 30 calendar days of the receipt of the grievance, unless additional information is needed, but cannot be obtained within this time frame. The notice of the decision will specify what you need to do to seek an additional review.
Appeals of Adverse Benefit Determinations by Aetna
Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests for appeal must be made in writing within 180 days from the date of the notice.
The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. You must complete the two levels of appeal before bringing a lawsuit. The following chart summarizes some information about how appeals are handled for different types of claims. In certain situations, the time frames shown may be extended.
You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. However, in case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal.
Depending on the type of appeal, you and/or an authorized representative may attend the Level 2 appeal hearing and question the representative of Aetna and any other witnesses, and present your case. The hearing will be informal. You may bring your physician or other experts to testify. Aetna also has the right to present witnesses.
If the Level One and Level Two appeals uphold the original adverse benefit determination, you may have the right to pursue an external review of your claim. See External review of Aetna’s final appeal determinations for more information.
External review of Aetna’s final appeal determinations
You may file a voluntary appeal for external review of any final appeal determination that qualifies.
You must complete the two levels of appeal described above before you can appeal for external review. Subject to verification procedures that may be established, your authorized representative may act on your behalf in filing and pursuing this voluntary appeal. You must request this voluntary level of review within 60 days after you receive the final denial notice.
If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action.
If you choose not to file for voluntary review, the Plan will not assume that you have failed to exhaust your administrative remedies because of that choice.
An external review is a review by an independent physician, with appropriate expertise in the area at issue, of claim denials and denials based upon lack of medical necessity, or the experimental or investigational nature of a proposed service or treatment. You may request a review by an external review organization (ERO) if:
- You have received notice of the denial of a claim by Aetna; and
- Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational; and
- The cost of the service or treatment in question for which you are responsible exceeds $500; and
- You have exhausted the applicable appeal process.
The claim denial letter you receive from Aetna will describe the process to follow if you wish to pursue an external review, and will include a copy of the Request for External Review Form.
You must submit the Request for External Review Form to Aetna within 60 calendar days of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request.
Aetna will contact the External Review Organization that will conduct the review of your claim. The External Review Organization will select an independent physician with appropriate expertise to perform the review. In rendering a decision, the external reviewer may consider any appropriate credible information submitted by you with the Request for External Review Form, and will follow the applicable plan’s contractual documents and plan criteria governing the benefits. You will generally be notified of the decision of the External Review Organization within 30 days of Aetna’s receipt of your request form and all necessary information. An expedited review is available if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the service would jeopardize your health. Expedited reviews are decided within 3-5 calendar days after Aetna receives the request.
You are responsible for the cost of compiling and sending the information that you wish to be reviewed by the External Review Organization to Aetna. Aetna is responsible for the cost of sending this information to the External Review Organization.
For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), the claims fiduciary is the person with complete authority to review all denied claims for benefits under the Plan. The claims fiduciary is Aetna for both medical Level One and Level Two and voluntary appeals, Magellan for mandatory and voluntary appeals for all mental health and appeals, and Express Scripts for all prescription drug mandatory and voluntary appeals. You may contact the claims fiduciary as follows:
This includes, but is not limited to, determining whether hospital or medical treatment is, or is not, medically necessary. In exercising its fiduciary responsibility, each claims fiduciary has discretionary authority on appeal to:
- Determine whether, and to what extent, you and your covered family members are entitled to benefits; and
- Construe any disputed or doubtful terms of the Plan.
Each claims fiduciary has the right to adopt reasonable policies, procedures, rules and interpretations of the Plan to promote orderly and efficient administration. A claims fiduciary may not act arbitrarily and capriciously, which would be an abuse of its discretionary authority.
The EMMP is responsible for making reports and disclosures required by ERISA, including the creation, distribution and final content of:
- Summary Plan Descriptions;
- Summary of Material Modifications; and
- Summary Annual Reports.